020.gingival enlargement

Dr Jaffar Raza Syed

Gingival Enlargement

What are the possible causes?

• Poor dental hygiene

• Smoking, mouth breathing and overcrowded teeth

• Systemic diseases

• Hormonal states: pregnancy, puberty

• Nutritional deficiency: scurvy (vitamin C deficiency)

• Medications

• Genetic conditions, often present at birth (all rare conditions)

• Blood conditions such as acute leukaemia

Dr Jaffar Raza Syed

Classification

According to etiological and

pathological changes

According to location and distribution

Dr Jaffar Raza Syed

Inflammatory enlargement

•Acute

•ChronicDrug-induced enlargement

or Non inflammatory

gingival enlargement

Enlargement associated with systemic diseases

•Conditioned enlargement

•Systemic diseases causing gingival enlargements

NeoplasticEnlargement

False Enlargement

CLASSIFICATION

A. According to etiologic factors and pathologic changes

I. Inflammatory enlargement

a. Chronic

b. Acute

II. Drug-induced enlargement

Dr Jaffar Raza Syed


• Acute

• Chronic

Drug-induced enlargement or

Non inflammatory gingival

enlargement


• Conditioned enlargement

• Systemic diseases causing gingival enlargements


False Enlargement

III. Enlargements associated with systemic diseases

a. Conditioned enlargement

(i) Pregnancy

(ii) Puberty

(iii) Vitamin C deficiency

(iv) Plasma cell gingivitis

(v) Nonspecific conditioned enlargement (Granuloma pyogenicum)

b. Systemic diseases causing gingival enlargements

(i) Leukemia

(ii) Granulomatous diseases

Dr Jaffar Raza Syed


•Acute

•Chronic


Non inflammatory



•Conditioned enlargement

•Systemic diseases causing gingival enlargements


False Enlargement

IV. Neoplastic enlargement (Gingival tumors)

a. Benign tumors

b. Malignant tumors

V. False enlargement

Dr Jaffar Raza Syed

B. According to location and distribution

Localized : Gingival enlargement limited to one or more (group of) teeth.

Generalized : Entire mouth, the gingiva is enlarged

Marginal : Limited to the marginal gingiva

Papillary : Confined to the interdental papilla

Diffuse : Involves all the parts of the gingiva, i.e. marginal, attached and

Interdental gingiva

Discrete : Isolated sessile or pedunculated tumor-like enlargement

Dr Jaffar Raza Syed

According to the Degree of Gingival Enlargement Grade 0 : No sign of gingival enlargement

Grade I : Enlargement confined to the interdental papilla

Grade II : Enlargement involves papilla and marginal gingiva

Grade III : Enlargement covers three quarters or more of the crown

Dr Jaffar Raza Syed

Acute inflammatory enlargement

Gingival abscess

Periodontal abscess

Periapicalabscess

Pericoronalabscess

Dr Jaffar Raza Syed

INFLAMMATORY ENLARGEMENT two types: a. Acute b. Chronic Acute Inflammatory Enlargement Signs and Symptoms a. Rapidly expanding lesion, usually limited to marginal gingiva or interdental papilla. b. red, painful swelling with teeth sensitive tom purcussion c. The lesion becomes fluctuant and pointed with a surface orifice from which purulent exudate may be expressed. Treatment --Vigourous OHM --Removal of abscess by I&D --Warm salt water mouthwashes used every 2 hours --Any residual pocketing can be removed by subgingival curettage or localized gingivectomy

Dr Jaffar Raza Syed

Dr Jaffar Raza Syed

Chronic Inflammatory Enlargement Types are: • Localized • Generalized • Discrete/Tumor-like. Localized/Generalized • It originates as a slight ballooning • In the early stages, it produces a lifesaver this bulge increases until it covers part of the crown • It progresses slowly and painlessly unless it is • discrete sessile or pedunculated the interproximal/marginal/attached gingiv

Chronic Inflammatory Enlargement

ballooning of the interdental papilla or margin

lifesaver-like bulge around the involved tooth and it covers part of the crown.

and painlessly unless it is complicated by acute infection or trauma

mass resembling a tumor. It may occur in interproximal/marginal/attached gingiva

papilla or marginal gingiva.

around the involved tooth and

complicated by acute infection or trauma.

mass resembling a tumor. It may occur in

Dr Jaffar Raza Syed

Etiology --prolonged local irritation

--poor oral hygiene,

--abnormal relationships of adjacent teeth and

opposing teeth,

--lack of tooth function,

--cervical cavities,

--overhanging margins of dental restorations,

--food impaction,

--irritation from clasps or saddle are

--nasal obstructions,

--habits such as mouth breathing and tongue thrusting

relationships of adjacent teeth and

dental restorations,

or saddle areas of removable prosthesis,

habits such as mouth breathing and tongue thrusting.

Dr Jaffar Raza Syed

Treatment

a. Scaling and curettage:

b. Surgical removal:

indicated for two reasons:

i. if it is fibrotic component

ii. If the size of the enlargement interferes with the access to the root surface deposits.

Surgical techniques include:

a. Gingivectomy technique.

b. Flap operation.

Dr Jaffar Raza Syed

convulsantsPhenytoin

Noninflammatory Gingival Enlargement (Fibrotic Gingival Enlargement)

produced by factors other than local irritation

Mostly are drug induced as

phenytoin,

cyclosporine,

nifedipine,

diltiazem,

verapamil and

sodium valproate


Non inflammatory


Anti-convulsantsPhenytoin

Calcium channel blockers

Nifedipine

immunosuppressant's

Cyclosporine


produced by factors other than local irritation.

immunosuppressant's

Cyclosporine

Idiopathic Gingival

Fibromatosis


Dr Jaffar Raza Syed

Phenytoin-induced Gingival Hyperplasi

--overgrowth usually becomes apparent --starts as a painless, bead-like enlargement and interdental papillae. --As the condition progresses, the marginal and papillary into a massive tissue fold covering a considerable portion of the crown and may interfere with the occlusion --hyperplasia is usually generalized --secondary inflammatory process

induced Gingival Hyperplasia

usually becomes apparent in the first three months after phenytoin dosage

ike enlargement of facial and lingual gingival margins

As the condition progresses, the marginal and papillary enlargement unite and develop covering a considerable portion of the crown and may

d but severe in max and mand anterior regions

secondary inflammatory process will complicates gingival hyperplasia caused by the dru

in the first three months after phenytoin dosage

of facial and lingual gingival margins

enlargement unite and develop covering a considerable portion of the crown and may

but severe in max and mand anterior regions

gingival hyperplasia caused by the drug

Dr Jaffar Raza Syed

Treatment --Oral hygiene reinforcement --Possible drug substitution --Professional recalls --surgical therapy a.Small areas of enlargement with no attachment loss b. Large areas of enlargement with presence of osseous

Small areas of enlargement with no attachment loss (Gingivectomy)

Large areas of enlargement with presence of osseous defect (periodontal flap)

defects

Dr Jaffar Raza Syed

Enlargements associated with systemic diseases

Conditional enlargement

Systemic diseases

causing gingival enlargments

Enlargements associated with systemic diseases

• Pregnancy

• Puberty

• Vitamin C deficiency

• Plasma cell gingivitis

• Non-specific conditioned enlargment(Granuloma pyogenicum)

• Leukemia

• Granulomatous diseases

causing gingival

enlargment

Dr Jaffar Raza Syed

Enlargement in Pregnancy --Aggravation of previous inflammatio --Pregnancy does not cause the condition. The altered pregnancy accentuates the response --bright-red or magenta, soft and friable and has a smooth, shiny surface --Bleeding occurs spontaneously or on slight provocatio --Tumor-like Gingival Enlargement or

ggravation of previous inflammation

Pregnancy does not cause the condition. The altered tissue metabolism in pregnancy accentuates the response to local irritation usually generalize

friable and has a smooth, shiny surface

or on slight provocation

like Gingival Enlargement or Pregnancy Tumor

tissue metabolism in usually generalized

friable and has a smooth, shiny surface.

Dr Jaffar Raza Syed

Treatment --Aim is to minimize the potential exaggerated inflammatory response related to hormonal alteration --Meticulous plaque control --The second trimester is the safest time in which treatment may be performed. However, long stressful appointment and periodontal surgical procedures should be postponed until postpartum --Fully reclining position should be avoided --Medication and radiographs should not be prescribed. --In case of marginal and interdental enlargement, scalingnand curettage can be performed. --In case of a tumor-like enlargement, surgical excision is required

Dr Jaffar Raza Syed

Enlargement in Puberty

Dr Jaffar Raza Syed

Nonspecific Conditioned Enlargement tumor-like gingival enlargement that is considered to be an exaggerated conditioned response to minor trauma. lesion varies from a discrete, spherical tumor-like mass with a pedunculated attachment to a flattened, keloid-like enlargement with a broad bas Treatment includes removal of the lesion along with the eliminationlocal irritating factors.

Nonspecific Conditioned Enlargement (Granuloma Pyogenicum)

like gingival enlargement that is considered be an exaggerated conditioned response

lesion varies from a discrete, spherical mass with a pedunculated attachment

like enlargement with a broad base

removal of the lesion along with the elimination of

Dr Jaffar Raza Syed

Systemic Disease Causing Gingival Leukemia The enlargement may be Diffuse

marginal, localized or generalized.

It may appear as an oversized extensionof the marginal gingiva or a discrete tumorinterproximal mass. Appearance bluish-red with a shiny surface. The consistency is moderately firm hemorrhage occurring either spontaneously or on sli True leukemic enlargement occurs commonly in acutesubacute leukemia. It seldom occurs in chronic leukemia

Systemic Disease Causing Gingival Enlargement

It may appear as an oversized extension marginal gingiva or a discrete tumor-like

red with a shiny surface.

consistency is moderately firm.

either spontaneously or on slight provocation.

True leukemic enlargement occurs commonly in acute leukemia but may also be seen in seldom occurs in chronic leukemia

leukemia but may also be seen in

Dr Jaffar Raza Syed

Treatment remove the local deposits

control inflammatory component of the enlargement

scaling and curettage

OHM and OHI

Antibiotics

Refer the patient to the physician for medical evaluation and treatment

Prior to chemotherapy, a complete periodontal treatment plan should be prepared

Monitor hematological lab values daily

During acute phases of leukemia, patients should receive only emergency periodontal

care

Dr Jaffar Raza Syed

Neoplastic enlargements

Benign tumors

Malignant tumors

Dr Jaffar Raza Syed

Benign Tumors of the Gingiva

• Fibroma

• Papilloma

• Peripheral giant cell granuloma

• Central giant cell granuloma

• Leukoplakia

• Gingival cyst

Malignant Tumors of the Gingiva • Malignant melanoma

• Sarcoma most commonly Kaposi's sarcoma

• Metastasis

Dr Jaffar Raza Syed

Scoring of gingival enlargement

Grade 0• No sign of gingival enlargement

Grade 1• Enlargement confined to the

Grade 2• Enlargement involves papilla and marginal

Grade 3• Enlargement covers three quarters or more of the crown

Scoring of gingival enlargement

No sign of gingival enlargement

Enlargement confined to the interdental papilla

Enlargement involves papilla and marginal gingiva

Enlargement covers three quarters or more of the crown

papilla

gingiva

Enlargement covers three quarters or more of the crown

Dr Jaffar Raza Syed

False Enlargement

not true enlargements of gingival tissues appear as a result of increase in size of the underlying osseous or dental tissues.

020.gingival enlargement

Health & Medicine